The Commonwealth Fund 1998 Survey of Women's Health reveals that while more women are receiving preventive care and taking better care of their health, they are still experiencing alarmingly high rates of violence and abuse, and many continue to have difficulties obtaining quality health care. The survey, which compares findings with the Fund's 1993 Survey of Women's Health, reveals no change in smoking rates and a considerable discrepancy in the receipt of needed health care among high-, medium-, and low-income groups. In addition, many women are caring for disabled relatives while balancing work and family responsibilities, yet they often have unmet health needs of their own and do not have the help they need to carry out their essential role. The survey consisted of telephone interviews with 2,850 women and 1,500 men conducted by Louis Harris and Associates, Inc., from May to November 1998.

Good and Bad News for Preventive Care and EducationThe good news is that more women age 50 and older, and especially more minority women, are receiving mammograms. The mammogram rate for minority women rose substantially, from 37 percent in 1993 to 66 percent for African American women in 1998, and from 54 percent to 64 percent for Hispanic women over that five-year period. Although more than four of five (83%) women age 50 and older with incomes above $50,000 had received a mammogram in the past year, only half (49%) of women with incomes of $16,000 or less had done so.

No improvement was found in the use of lifesaving preventive services such as Pap tests and clinical breast exams, however, and colon cancer screening rates were low: only one of four (25%) women received this test. Women in managed care plans reported higher rates of some preventive care: three of four (74%) had received a Pap test in the past year, compared with two of three (67%) women in fee-for-service.

Awareness of the importance of healthy behaviors has also increased. Women are more knowledgeable about osteoporosis and are taking calcium supplements to help prevent the condition, and more women are exercising. The survey also found that physicians are more likely to counsel women about exercise (49%) and diet or weight (46%) than more difficult issues such as smoking (29%), alcohol or drug use (23%), sexually transmitted diseases (16%), or violence in the home (8%).

HRT Use Linked to Education and IncomeThe proportion of women age 50 and older using hormone replacement therapy (HRT) grew from less than one of four (23%) in 1993 to one of three (34%) in 1998. Use of HRT corresponds to education and income: one of five (22%) older women with less than a high school education used HRT, compared with half (49%) of women with a college degree. Only one of five (21%) older women with an income of $16,000 or less used HRT, compared with more than half (57%) with incomes above $50,000.

High Rates of Violence and Abuse FoundThe 1998 survey was the first to ask women nationwide about their lifetime experiences with abuse and violence, and rates were found to be disturbingly high. Nearly two of five women (39%) reported experiences with either childbood abuse, rape or assault, or domestic abuse. Nearly one of three (31%) women reported that she had experienced violence or physical abuse from a spouse or partner. Three percent of women, or 3 million women nationwide, reported experiencing domestic abuse in the past year. One of five (21%) women had been raped or assaulted in her lifetime.

The survey revealed strong links between abuse and a wide range of negative health effects and experiences, including higher rates of depression, reports of fair or poor health, and problems obtaining access to health care.

The link between abuse and mental health is striking: more than half (53%) of women reporting a history of any abuse or violence-whether domestic abuse, childhood abuse, rape, or assault-had a high level of depressive symptoms, compared with 30 percent of women who said they had not been abused or experienced violence.

Women with depression or anxiety often fail to receive mental health care. Among women with high depressive symptoms, only one of five saw a mental health professional in the past year.

Low Incomes and Lack of Insurance Linked to Access and Health ProblemsLow-income women were found to be at greater risk for physical and mental health problems on virtually every measure. Those with incomes of $16,000 or less were six times as likely to report fair or poor health as women with family incomes above $50,000 (32% vs. 5%). More than half (55%) of women in the lowest income category reported high levels of depressive symptoms and were more than twice as likely to report a physician diagnosis of depression or anxiety compared with higher-income women (26% vs. 12%).

Despite tight labor markets in a thriving economy, in 1998 the proportion of working-age women without health insurance increased. One of four (26%) women ages 18 to 64 was either uninsured (18%, up from 14% in 1993) or had spent a time without insurance at some time in the past year (8%). Women with low incomes were the hardest hit-a possible indication of the effect of women leaving welfare rolls for low-wage jobs that do not provide health insurance. More than one of three (35%) women with incomes of $16,000 or less were uninsured, up from 29 percent in 1993. In contrast, only 5 percent of women with incomes above $50,000 lacked insurance.

Working-age uninsured women and those who had a lapse in coverage during the past year had lower rates of preventive care and more access problems than those who were continuously insured. While one of six (17%) continuously insured women had at least one of three access problems (did not get needed care or specialty care or did not fill a prescription because of cost), two of five (40%) women who had spent a time uninsured and nearly half (46%) of women currently uninsured had at least one access problem.

African American and Hispanic women were more likely than white women to be uninsured: while one of eight (13%) white women under age 65 lacked insurance, nearly one of four (23%) African American and more than two of five (42%) Hispanic women were uninsured. Hispanic women also had the greatest increase in lack of insurance since 1993, from 33 percent to 42 percent. Some education messages are not reaching minority women: black women (25%), Hispanic women (19%), and Asian American women (17%) were all less likely to say they were ""very familiar"" with osteoporosis than were white women (41%).

Facts and Figures

Rates for receipt of clinical breast exams (66%) and Pap tests (64%) remained the same from 1993 to 1998. The rate of women age 50 and older receiving a mammogram increased from 55 percent to 61 percent.

Two-fifths (39%) of women have experienced violence or abuse as a child or adult. Half of women who revealed any type of abuse exhibited high levels of depressive symptoms, compared with one of three women with no history of violence.

Over one-third (35%) of low-income women are uninsured. Half of uninsured women reported not having a regular doctor.

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Mission

The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.